In the last 24 hours, using a scale from 1=not at all to 7=extremely, how much have you been bothered by…
	Not at all 1	2	3	4	5	6	Extremely 7	Refuse to Answer
Feeling upset	❍	❍	❍	❍	❍	❍	❍	❍
Thinking about food a lot	❍	❍	❍	❍	❍	❍	❍	❍
Wanting to smoke	❍	❍	❍	❍	❍	❍	❍	❍
Troubled sleep	❍	❍	❍	❍	❍	❍	❍	❍
Feeling restless	❍	❍	❍	❍	❍	❍	❍	❍
Having trouble concentrating	❍	❍	❍	❍	❍	❍	❍	❍
Feeling unhappy	❍	❍	❍	❍	❍	❍	❍	❍
Eating a lot	❍	❍	❍	❍	❍	❍	❍	❍
Having urges to smoke	❍	❍	❍	❍	❍	❍	❍	❍
Feeling tired	❍	❍	❍	❍	❍	❍	❍	❍
Having trouble sitting still	❍	❍	❍	❍	❍	❍	❍	❍
Having trouble paying attention	❍	❍	❍	❍	❍	❍	❍	❍
Feeling stressed	❍	❍	❍	❍	❍	❍	❍	❍
Feeling hungry	❍	❍	❍	❍	❍	❍	❍	❍
Thinking about smoking	❍	❍	❍	❍	❍	❍	❍	❍
Waking frequently during the night	❍	❍	❍	❍	❍	❍	❍	❍
Feeling fidgety	❍	❍	❍	❍	❍	❍	❍	❍
Having trouble thinking clearly	❍	❍	❍	❍	❍	❍	❍	❍
Feeling angry	❍	❍	❍	❍	❍	❍	❍	❍